Clinical Insights/Professional Update





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Choose article section... What influences a physician's career satisfaction? Labor Department issues new appeals rules for health plans Couple claiming wrongly implanted ova denied paternity testing How satisfied are your hysterectomy patients? Same-day appointments, increased productivity CLINICAL INSIGHTS Shortened postpartum hospital stay: safe but no bargain? Oxytocin: Still No. 1 for third-stage labor Finally, proof that C-sections reduce mother-to-infant HSV transmission Estrogen doesn't protect against reinfarction Minor changes in thyroid function can have major effects on the heart Comparing MgSO

What influences a physician's career satisfaction?

While managed-care penetration had little effect on how satisfied primary-care physicians and specialists were over time, changes in their clinical autonomy, income, and practice ownership did predict satisfaction levels, according to a recent study in the Journal of the American Medical Association (1/22-29/03).

Between 1997 and 2001, changes in clinical autonomy were "the most consistent predictors of changes in both PCP and specialist career satisfaction." The researchers also found that PCPs who had to treat more complex patient problems without referral were more likely to report decreased satisfaction. For both PCPs and specialists, increased difficulty in obtaining outpatient and inpatient services resulted in decreased career satisfaction.

As you might expect, income levels also influenced satisfaction levels among PCPs, according to the study. But among specialists, income was not related to satisfaction.

The investigation also found that PCPs and specialists who became owners of their practices were more likely to report increased satisfaction with their careers. But on the other hand, those PCPs who reported increases in their work hours—from less than 60 hours per week to more than 60 hours per week—reported decreased satisfaction.

The study is based on data collected from the Community Tracking Physician Survey, a series of nationally representative telephone surveys of physicians in 60 US sites conducted in 1996–1997, 1998–1999, and 2000–2001.

Labor Department issues new appeals rules for health plans

After several delays, all health plans sponsored by employers or regulated by the Employee Retirement Income Security Act (ERISA) must now comply with Department of Labor rules requiring quicker turnaround times for claims and appeals.

Among the regulations, health plans must now return decisions for initial claims and appeals deemed "urgent" by the treating physician within 3 days, reported American Medical News (1/20/03). Moreover, plans cannot charge fees as a condition for filing an appeal. (The rules, which had been a holdover from the Clinton administration, took effect on Jan. 1.)

According to the AMNews report, the regulations stipulate that someone other than the person who handled the initial claim must review an appeal, and that person must review the claim in its entirety, "without reference to previous denials."

The rules also require that claimants be given access to any information relevant to a denied claim, and plans must provide full and detailed explanations of why a claim is denied. Moreover, plans must consult health-care professionals when considering appealed claims that involve medical judgment, and the names of these health-care professionals must be provided to claimants.

Couple claiming wrongly implanted ova denied paternity testing

A couple who believed that their fertilized ova had been wrongly implanted into another woman are not entitled to have paternity testing on, or visitation with, the resultant twins. That was the recent ruling of the California Court of Appeal, Second Appellate District.

According to BNA's Health Law Reporter (11/14/02), the Morrisons had been patients at a reproductive health center for implantation of their own fertilized ova, but did not conceive. Years later, they discovered that the health center had been involved in placing fertilized ova from one patient to another without the donor's consent. The Morrisons, along with others, sued the health center and ultimately settled the suit.

During the discovery process for the suit, however, the couple learned that their prepared ova may have been implanted into another woman, resulting in twins for the Doe family. Wanting to establish a parental relationship and obtain visitation privileges, they sought legal action.

To support their case, the Morrisons offered a "declaration" from a lab technician, who claimed that some of the Morrison's prepared ova had been implanted into the mother of the twins. In response, the Does claimed that the lab technician's declaration was hearsay, and the trial court agreed.

BNA's Health Law Reporter noted that the Morrisons maintained on appeal that "they should be allowed to discover whether the twins were born 'as a result of the theft of their genetic material,' and that their rights outweighed those of the Does.

The appellate judge disagreed and concluded that the "Morrisons' 'rights' were vindicated when they settled their case against the center," and the Doe family had "the right to be free from interference of strangers who have no standing to pursue their demands for blood tests or visitation rights."

How satisfied are your hysterectomy patients?

Low-income women who undergo a hysterectomy are less satisfied with their care than women with private insurance, according to a study appearing in the American Journal of Obstetrics and Gynecology (12/02). Specifically, the low-income women reported being more tired, moody, and depressed 3 months post-op, and they were less satisfied with the information provided on what to expect after the operation, less well overall post-op, and less willing to recommend a hysterectomy to a friend with similar problems.

In contrast, the study found that women with private insurance were less likely than low-income women to report satisfaction with their sex life, body image, ability to perform daily activities, and speed of recovery.

Despite the contrasting areas of dissatisfaction, the researchers did find that nearly all of the women—98% of low-income women and 100% of women with private insurance—reported that their symptoms had improved after surgery.

Same-day appointments, increased productivity

Seeing patients on the same day that they call for an appointment—a practice strategy known as advanced or open access—has resulted in satisfied patients, physicians, and staff; fewer no-shows; higher-quality care and increased revenue for some practices, according to a report in Managed Care (12/02).

Advanced access involves allowing patients to choose whether to schedule their appointment on the same day of their call, the next day, or the next week. While this helps take care of office visit backlogs, the strategy also includes making referrals to other providers and completing "process work," such as documentation, prescription refills, and laboratory reviews, on the same day.

To implement advanced access in a practice, you may want to visit the Institute for Healthcare Improvement's Web site at , and follow a few basic steps:

• Determine your practice's demand for appointments and supply of appointments daily. Find out how much time elapses between when an appointment is requested (demand) and when the appointment is actually made (supply); this gap is "the access problem."

• Eliminate the backlog. To do this, hire more staff such as a medical assistant or nurse practitioner, and put in longer hours. One Colorado-based physician implemented this step toward advanced access and is seeing more patients per day, takes home more pay, and has more satisfied patients and staff.

• Get rid of appointment types (such as routine, urgent, or new patient). Instead, create a more flexible appointment schedule, allowing appointments to be made at any time, regardless of type.

• Develop contingency plans. Determine how work will be divided in case a provider is on vacation or has the day off, or even during peak days or hours.

• Reduce demand for unnecessary visits by having doctors see their own patients—a strategy that will reduce demand by about 10%—and by doing as much as possible with each visit.


Shortened postpartum hospital stay: safe but no bargain?

Early postpartum hospital discharge may be safe for many mothers and their infants, but it doesn't save insurers money, according to a recent Harvard study.

To reach that conclusion, researchers looked at more than 7 years of data on over 20,000 mother-infant pairs before and after Massachusetts enacted its 48-hour minimum hospital stay policy in February 1996. The policy reversed early hospital discharge protocols established by many health maintenance organizations in an effort to cut costs.

The investigators found no increase in emergency department visits or hospital readmissions associated with a 1-night postpartum hospital stay as compared to a 2-night stay, although the rate of nonurgent visits to health centers increased from 33.4% to 44.7%.

Because the HMO early discharge program examined in the study provided for a home visit by a nurse within 48 hours of discharge, the rate of newborn examinations on the third or fourth day of life increased from 24.5% to 64.4% and then decreased to 53% with the 48-hour hospital stay mandate.

Partly because of the home nurse visit and partly because of changes in hospital pricing, cost savings to the HMO as a result of the shortened hospital stay were only about $90 per mother-infant pair.

Madden JM, Soumerai SB, Lieu TA, et al. Effects of a law against early postpartum discharge on newborn follow-up, adverse events, and HMO expenditures. N Engl J Med. 2002;347:2031-2038.

Oxytocin: Still No. 1 for third-stage labor

Injectable oxytocin and oxytocin-ergot combinations are more effective for the prevention of postpartum hemorrhage and cause fewer adverse effects than the prostaglandin misoprostol, says a review of 16 randomized trials from around the world.

Compared to misoprostol, injectable uterotonics were associated with less significant blood loss and a less frequent need for additional uterotonic agents. At least three trials that compared rectal misoprostol (400 µg) to injectable uterotonics, for instance, found that the former increased the likelihood of patients needing additional uterotonics by 80%.

In addition, women given misoprostol were more than three times as likely as women given injectable uterotonics to experience shivering and almost seven times as likely to develop fever.

The authors cautioned, however, that most of the trials in the analysis did not have the statistical power to determine if the two agents were clinically equivalent, and that even the best strategy will still leave approximately 3% of women worldwide losing in excess of 1,000 mL of blood after delivery.

Villar J, Gulmezoglu AM, Hofmeyr JG, et al. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstet Gynecol. 2002;100:1301-1312.

Finally, proof that C-sections reduce mother-to-infant HSV transmission

After 30 years of cesarean sections being the standard of care for women with genital herpes at the time of delivery, proof now exists that the procedure does in fact reduce the rate of neonatal herpes simplex virus (HSV) infection.

In a recent study involving almost 60,000 women, cesarean delivery significantly reduced the HSV transmission rate among women from whom HSV was isolated. Only 1.2% of women delivering via C/S, versus 7.7% of the women delivering vaginally, transmitted HSV to their infants.

The study found that while the infants of women with all HSV serologic classifications are at risk, the highest risk exists among HSV seronegative women. Women with previous HSV-2 infection are at reduced risk for transmitting HSV-2 to their infants and at essentially no risk of transmitting HSV-1.

The authors of the study explained that vertical transmission is strongly influenced by how labor is managed and greatly depends on whether maternal herpes is recognized and whether fetal skin integrity is maintained during labor. Consequently, invasive monitoring increases risk, as does first-episode infection, HSV isolation from the cervix, HSV-1 or HSV-2 isolation at the time of labor, delivery before 38 weeks, and maternal age of less than 21 years.

Brown ZA, Wald A, Morrow A, et al. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA. 2003;289:203-209.

Estrogen doesn't protect against reinfarction

Estrogen therapy does not seem to protect postmenopausal women who have survived a myocardial infarction from future cardiac events, according to a randomized, placebo-controlled trial.

Researchers studied about 1,000 women between the ages of 50 and 69 years who survived a first MI. The women received either 1 tablet of estradiol valerate (2 mg) or placebo daily for 2 years.

Although the rate of death from all causes was lower at 2 years in the unopposed estrogen group than in the placebo group (because of a slightly lower rate of cardiac deaths), the difference was not significant.

The authors of the study cautioned, however, that the trial lacked the power to unearth small differences in risk, and that compliance, particularly by the women in the active treatment arm, was poor, primarily because of bleeding.

ESPRIT team. Oestrogen therapy for prevention of reinfarction in postmenopausal women: A randomised placebo controlled trial. Lancet. 2002;360:2001-2008.

Minor changes in thyroid function can have major effects on the heart

Contrary to traditional thinking, subclinical thyroid dysfunction—highly prevalent in the general population—requires timely treatment in order to avoid adverse cardiovascular effects, according to this recent critical analysis.

After reviewing 30 years of clinical information, Italian researchers concluded that subclinical hypothyroidism is associated with impaired left ventricular diastolic function at rest, systolic dysfunction on exertion, and an increased risk of atherosclerosis and myocardial infarction. Subclinical hyperthyroidism was also linked to increased heart rate, atrial arrhythmias, increased left ventricular mass with marginal concentric remodeling, impaired ventricular relaxation, reduced exercise performance, and an increased risk for cardiovascular death.

All abnormalities were reversed or blunted when thyroid function returned to normal.

Biondi B, Palmieri EA, Lombardi G, et al. Effects of subclinical thyroid dysfunction on the heart. Ann Intern Med. 2002;137:904-914.

Comparing MgSO4 to nimodipine for preeclamptic seizures

Intravenous magnesium sulfate (MgSO4) is more effective than oral nimodipine, a cerebral vasodilator, at preventing seizures in women with severe preeclampsia, according to a controlled, comparative, multicenter trial. The finding suggests that eclampsia is caused by cerebral over- rather than under-perfusion.

The trial, which involved 1,650 women, found that the women who received nimodipine were about three times more likely to have a seizure than those who received MgSO4. While the antepartum seizure rate did not differ significantly between the two groups, the nimodipine group had a significantly higher rate of postpartum seizures. Neonatal outcomes did not differ significantly between the two groups.

Independent risk factors for eclampsia in women with severe preeclampsia include chronic hypertension, systolic blood pressure of greater than 180 mm Hg on admission, the need for additional hydralizine to control blood pressure, a serum sodium level less than 136 mmol/L, and young age.

Belfort MA, Anthony J, Saade GR, et al. A comparison of magnesium sulfate and nimodipine for the prevention of eclampsia. N Engl J Med. 2003;348:304-311.


Professional Update/Clinical Insights. Contemporary Ob/Gyn Apr. 1, 2003;48:12-19.

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